The Rehabilitation Center of Bakersfield

In the surveyor’s words

From the most serious findings on record at The Rehabilitation Center of Bakersfield, in the surveyor’s own words.

• Actual harm, isolatedF658Nov 4, 2025

  Based on interview and record review, the facility failed to ensure Licensed Vocational Nurse (LVN) 1 obtained complete vital signs (heart rate, temperature, respiration [breathing] rate, and blood pressure [force of blood on the walls of the blood vessels as the heart pumps blood around the body] that indicate a person's essential body functions) for one of three sampled residents (Resident 1) when Certified Nursing Assistant (CNA) 1 was unable to obtain viable vital signs after four attempts. […]

• Actual harm, isolatedF689Nov 19, 2024

  Based on interview and record review, the facility failed to follow its policy and procedure (P&P) titled, Fall Management Program, for one of three sampled resident (Resident 2) when the facility failed to: 1. Complete the Post Fall Evaluation (PEE- document to help identify possible causes of a fall and prevent future falls). 2. Develop a care plan (personalized plan of care outlining a person ' s needs and how they will be addressed) to prevent future falls for Resident 2. These failures resulted in Resident 2 falling multiple times in five months and sustaining left intertrochanteric (are bony protrusions on the thighbone) femoral (thigh bone) fracture (broken bone) requiring surgical operation. Findings: 1. […]

• Actual harm, isolatedF656Jul 25, 2024

  Based on observation, interview, and record review, the facility failed develop and implement a care plan (CP- provides direction on the type of nursing care the individual may need) for one of three sampled residents (Resident 1) identified as high risk for developing pressure injuries (PI- is localized damage to the skin and underlying soft tissue usually over a bony prominence). This failure resulted in Resident 1 developing a DTI (deep tissue injury- intact or non-intact skin with localized area of persistent non-blanchable [the skin does not turn white when touched with a finger] deep red, maroon, purple discoloration or epidermal [outer layer of skin] separation revealing a dark wound bed or blood-filled blister [raised skin filled with fluid]) in left foot, a blister to right heel… […]

• Actual harm, isolatedF692Jul 25, 2024

  Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1) received the prescribed nutrition (three meals a day: breakfast, lunch, and dinner) to meet nutritional needs and maintain desirable weight. This failure resulted in a 24.5- pound weight loss and 17.3 percent (%) of body weight in two months for Resident 1. Findings: During a concurrent observation and interview on 5/16/24 at 1:03 p.m. with Certified Nursing Assistant (CNA) 3 outside Resident 1's room. CNA 3 stated she was assigned to Resident 1. There was no lunch meal tray noted in Resident 1's room. CNA 3 confirmed Resident 1 did not have a lunch meal tray in his room. […]

• Actual harm, isolatedF689May 30, 2024

  Based on observation, interview, and record review, the facility failed to ensure the environment was free of accident hazards when one of 22 sampled residents of (Resident 1) was allowed to smoke unsupervised with oxygen applied. This resulted in Resident 1 sustaining second degree burns (partial thickness burns involving the top two layers of the skin) to the right and left cheeks. Findings: During a review of Resident 1's Admission Record, (AR) the AR indicated, Resident 1 is an [AGE] year-old male, admitted on [DATE], with the following diagnoses: Dementia (is not a single disease, but a term for range of conditions that affect the brain's ability to think, remember, and function normally) with psychotic disturbances (refers to the mental state where person has trouble figuring out… […]